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Economic Models of Colorectal Cancer Screening in Average-Risk Adults

Workshop Summary

National Cancer Policy Board

Board on Science, Technology, and Economic Policy

Policy and Global Affairs Division

Michael Pignone, Louise Russell and Judith Wagner, Editors

INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary Economic Models of Colorectal Cancer Screening in Average-Risk Adults Workshop Summary National Cancer Policy Board Board on Science, Technology, and Economic Policy Policy and Global Affairs Division Michael Pignone, Louise Russell and Judith Wagner, Editors INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Contract No. N01-OD-4–2139 between the National Academy of Sciences and the National Cancer Institute. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number 0-309-09539-5 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2005 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm. A.Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary NATIONAL CANCER POLICY BOARD JOSEPH SIMONE (Chair), Simone Consulting, Dunwoody, GA ELLEN STOVALL (Vice Chair), Executive Director, National Coalition for Cancer Survivorship, Silver Spring, MD BRUCE W. STILLMAN (Vice Chair), Director, Cold Spring Harbor Laboratory, Cold Spring Harbor, NY JILL BARGONETTI, Associate Professor, Department of Biological Sciences, Hunter College, New York, NY TIMOTHY EBERLEIN, Bixby Professor and Chairman, Department of Surgery, Washington University School of Medicine, St. Louis, MO KATHY GIUSTI, President, Multiple Myeloma Research Foundation, New Cannaan, CT KAREN HERSEY, Senior Counsel, Massachusetts Institute of Technology, Cambridge, MA JIMMIE C.HOLLAND, Chair, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY WILLIAM KAELIN, Professor, Harvard Medical School, Boston, MA WILLIAM McGUIRE, Chief Executive Officer, UnitedHealth Group, Minnetonka, Minnesota JOHN MENDELSOHN, President, M.D. Anderson Cancer Center, University of Texas, Houston, TX KATHLEEN HARDIN MOONEY, Professor, University of Utah College of Nursing, Salt Lake City, UT PATRICIA NOLAN, Director, Rhode Island Department of Health, Providence, RI DAVID PARKINSON, Oncology Therapeutic Area Head, Amgen, Inc. Thousand Oaks, CA JOHN POTTER, Senior Vice President and Director, Cancer Prevention Research Program, Fred Hutdchinson Cancer Research Center, Seattle, WA LOUISE RUSSELL, Professor, Rutgers University, New Brunswick, NJ THOMAS J.SMITH, Professor, Virginia Commonwealth University, Richmond, VA ROBERT C.YOUNG, Past-President, American Cancer Society and President, the Fox Chase Cancer Center, Philadelphia, PA Study Staff JUDITH L.WAGNER, Scholar in Residence, Institute of Medicine ELIZABETH J.BROWN, Research Assistant ANIKE L.JOHNSON, Administrative Assistant MARY ANN F.PRYOR, Project Assistant LOUISE B.RUSSELL, Research Professor, Institute for Health, Health Care Policy and Aging Research, Rutgers University, Workshop Chair MICHAEL P.PIGNONE, Assistant Professor of Medicine, University of North Carolina

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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary REVIEWERS All presenters at the workshop have reviewed and approved their respective sections of this report for accuracy. In addition, this workshop summary has been reviewed in draft form by independent reviewers chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine (IOM) in making the published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The National Cancer Policy Board and IOM thank the following individuals for their participation in the review process: John Inadomi, University of Michigan Medical Center and VA Ann Arbor Health Care System David Lieberman, Oregon Health Sciences University Diana Petitti, Kaiser Permanente of Southern California David Ransohof, University of North Carolina at Chapel Hill The review of the report was overseen by Clyde J.Behney, Deputy Executive Director, IOM, who was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the editors and the institution.

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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary TABLE OF CONTENTS     INTRODUCTION AND BACKGROUND   1     THE COLLABORATIVE MODELING EXERCISE   2      Origin of the Exercise   2      General Approach   3      Results   12      Lessons Learned from the Exercise   19     MAJOR CHALLENGES TO MODELING THE COST-EFFECTIVENESS OF CRC SCREENING   22      Uncertainty   23      Modeling Reality or an Ideal World?   27      How Complex Should Models Be?   28     NEXT STEPS   29     REFERENCES   31     APPENDIXES     A   Workshop Agenda: Economic Models of Colorectal Cancer Screening in Average-Risk Adults   35 B   Workshop Participants   37 C   Workshop Speaker and Staff Biographies   39 D   Overview Of Harvard Model: Karen M.Kuntz, ScD.   47 E   Description of the Laudabaum Colorectal Cancer Screening Model: Uri Ladabaum, M.D., M.S.   61 F   MISCAN-colon: An Overview: Marjolein van Ballegooijen, Iris Vogelaar, Rob Boer, Franka Loeve, Ann Zauber, Gerrit van Oortmarssen, and Dik Habbema   73 G   The Vanderbilt Colorectal Cancer Model R.M.Ness, R.W.Klein, R.S.Dittus   84 H   Overview of the Vijan: Colorectal Cancer Screening Model: Sandeep Vijan, M.D., M.S.   105 I   Cost-Effectiveness Analyses of Colorectal Cancer Screening: Results from a Pre-conference Modeling Exercise: Michael Pignone, M.D., M.P.H.   118 J   Recent Findings on Test Performance: Brian P.Mulhall, M.D., M.P.H.   154 K   Cost Issues in Cost Effectiveness Modeling of Colorectal Cancer Screening: Martin L.Brown, Ph.D.   189 L   Current Evidence on Compliance: Sally W.Vernon, M.A., Ph.D.   208 M   Recent Trends in Follow-up Surveillance in Medicare Beneficiaries: Todd Anderson, M.S   220 N   Preliminary Results from CDC’s Estimate of the National Capacity for Colorectal Cancer Screening and Follow-Up: Laura C.Seeff, M.D.   232 O   Colorectal Cancer Surveillance Testing After Polypectomy: Deborah Schrag, M.D., M.P.H.   241

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Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary P   Natural History of Colorectal Adenomas and Cancer: T.R.Levin, M.D.   263 Q   CISNET—Cancer Intervention and Surveillance Eric J. (Rocky) Feuer, Ph.D.   285 TABLES AND FIGURES TABLES 1   Summary of Standardized Assumptions: Pre-workshop Exercise     2   Basic Assumptions: Pre-workshop Exercise     3   Summary of Original Assumptions     4   Settings for Experimental Runs: Pre-workshop Exercise     5   Predicted Years of Life Lived and Lifetime CRC Costs per Capita, No Screening: Original Model Assumptions     6   Incremental Cost-Effectiveness Ratios of Five CRC Screening Strategies: Original Assumptions     7   Incremental Cost-Effectiveness Ratios of Five CRC Screening Strategies: Standardized Assumptions     8   Effect of Standardizing Individual Assumption Groups on Variation Across Models: Ratio of Highest Estimate to Lowest Estimate     9   Effect of Standardizing Specific Assumption Groups on Variation in Cost-Effectiveness Ratios Across Models-Ratio of Highest Estimate to Lowest Estimate     10   Impact of Excluding Non-Adenomatous Polyps from the Vanderbilt Model     11   Impact of Detecting Non-Adenomas on Incremental Cost-Effectiveness Ratios     FIGURES 1a   Years of life gained from screening: original assumptions     1b   Lifetime costs of screening: original assumptions     2   Cost-effectiveness of screening: original assumptions     3a   Years of life gained from screening: standardized assumptions     3b   Lifetime costs of screening: standardized assumptions     4   Cost-effectiveness of screening: standardized assumptions